Transcript Neonatal ECMO - University of Washington

Neonatal ECMO
Chris Burke MD
March 6, 2014
Basics
• Types
– Veno-arterial (VA): full cardiopulmonary support
– Veno-venous (VV): pulmonary support only
• Requires systemic anticoagulation
• Perfusionist necessary to operate pump; differential
flows allow for maximal support/weaning
• Multiple complications exist: access site issues,
bleeding, HIT, and thrombus formation
Types
VA
VV
History of ECMO
History of ECMO
• John Gibbon credited with the
first use of a prosthetic heart-lung
machine for cardiac surgery in
1953
• Early CPB was lethal after several
hours
• Kolobow, Bartlett, and others
demonstrated that extracorporeal
circulation of the blood could be
carried out for days or weeks
without toxicity or hemolysis, as
long as direct blood-gas contact
was avoided
History of ECMO
• First successful ECMO case was
in 1972 in San Francisco
• Bartlett and his team performed
first neonatal ECMO case in
1975 at UC-Irvine
• Bartlett then moved to the
University of Michigan,
establishing the first neonatal
ECMO program in 1980
• The extracorporeal life support
organization (ELSO) is formed
in 1989
Bartlett et al 1985
• Bartlett and his team had established safety of
ECMO with case series in the late 1970s and
early 1980s
• In infants with birth weight greater than 2kg,
survival on ECMO was 70%; in contrast to a
20% survival rate for infants treated with best
medical management
• The stage was set for the first randomized
“phase 2” trial in neonates
Bartlett et al 1985
• Trial utilized a unique,
“randomized play-thewinner” design
• Neonates greater than 2kg
with a greater than 90%
chance of demise were
selected for the trial
Bartlett et al 1985
• During the 18 months of
enrollment, 12 patients were
ultimately randomized
• 1 neonate in the control group; 11
in the ECMO cohort
• Conventional treatment included
maintaining PaO2 70-150 mmHg,
hyperventilation +/- bicarb
infusion to maintain PaCO2 < 35
mmHg and pH > 7.5
Bartlett et al 1985
Bartlett et al 1985
Control patient died of progressive respiratory failure 13 days after randomization
Bartlett et al 1985
• Unique study design, but laid the ground-work
for ECMO becoming routine in critically ill
neonates
• Long-term sequela were unknown
– Four children went on to have developmental
delay or mild neurologic problems
• This trial and other early reports led to the
establishment of several ECMO programs
throughout the US
Low Birth Weight Infants
LBW Infants
• Many guidelines suggest that ECMO may not
be safe for neonates less than 2kg
• Early reports in LBW infants revealed a nearly
80% mortality rate in this cohort
• Concern over hemorrhagic complications,
notably intracranial hemorrhage
LBW Infants
• Authors sought to challenge the idea that
ECMO is not safe in infants less than 2kg
• Utilized the ELSO registry to obtain data on
14,305 neonates placed on ECMO between
1991-2002
– 13,642 HBW (greater than 2 kg)
– 663 LBW (less than 2 kg)
LBW Infants
LBW Infants
LBW Infants
• Though survival in LBW infants is lower, it is still
53%, which is similar to the rate in older patients
after cardiac failure and may be higher than the
expected outcome if ECMO were not used in these
cases
• Infants weighing 1.6kg or more have an expected
ECMO survival of 40%
• Fatal bleeding more common in LBW infants more
conservative anticoagulation strategy needed?
• Selection bias may be present limitation of registry
study
Long-term Outcomes
Jaillard et al 2000
• Single center retrospective review sought to
evaluate long-term outcomes in neonatal
ECMO
• All cases of ECMO reviewed from Oct 1991Sep 1997
• Infants were followed with serial
neurodevelopmental, respiratory, and digestive
evaluations
Jaillard et al 2000
• 57 infants enrolled in the study
– CDH (n=23), sepsis (n=14), MAS (n=12), others (n=8)
• Mean time of onset was 70 h
• Mean duration of ECMO was 134 h
Jaillard et al 2000
• Survival at two-years was 40/57 (70%)
– CDH 52%, NS 79%, MAS 100%, others 62%
• Ten neonates died on ECMO
• Five technical complications were noted on ECMO
– Pump malfunction (2), air in circuit (1), hemorrhage (1), heat
exchanger malfunction (1)
Jaillard et al 2000
• Two infants with clinical vision anomalies; one infant with
severe hearing loss requiring prosthesis
• 45% of infants were oxygen-dependent at 28 days (83% CDH)
– Four infants required tracheostomy (all CDH)
– Two infants were O2 dependent at two-years (both CDH)
• Growth retardation in 12 infants; GERD noted in 11
– Four required G-tube (all CDH)
• 95% of carotid reconstructions were patent at two-years
Jaillard et al 2000
• Survival was high in all groups with limited
morbidity; however, CDH infants fared worse
than their counterparts
• All carotid arteries were reconstructed with
good anatomic outcome
• Neonates with CDH remain a significant
challenge
Congenital Diaphragmatic
Hernia
CDH
• Between 20-40% of infants with CDH require
ECMO rescue therapy
• VA ECMO has traditionally been the
predominant form in CDH
• VV ECMO has several advantages
– Spares ligation of the carotid artery
– Minimizes embolic risk to the brain
– Perfusion of the pulmonary vasculature
– Maintenance of pulsatile flow
VV vs. VA
• Disease-severity risk-adjusted analysis of VV and VA ECMO
outcomes in CDH
• Utilized the ELSO database (1991-2006)
• Primary outcome was in-hospital mortality; secondary
outcomes included complication rates
VV vs. VA
VV vs. VA
VV vs. VA
• No differences in the risk-adjusted odds of mortality
between infants with CDH undergoing VV vs. VA
ECMO [46% vs 50%, p=.03]
• Echocardiographic data was excluded from this
analysis
• 18% conversion rate from VV to VA ECMO; this
carried a 56% mortality rate
• VV ECMO may be a feasible option in infants with
CDH